The DSM is the categorization United States mental health "experts" use on us. DSM-IV is the most recent version published in 1994. According the the HBSOC:

DSM - IV

The diagnosis of Transsexualism was introduced in the DSM-III in 1980 for gender dysphoric individuals who demonstrated at least two years of continuous interest in removing their sexual anatomy and transforming their bodies and social roles. Others with gender dysphoria could be either diagnosed as Gender Identity Disorder of Adolescence or Adulthood Nontranssexual Type or Gender Identity Disorder Not Otherwise Specified
(GIDNOS). These diagnostic terms were ignored by the media who used the term transsexual for any person who wanted to change or had changed sex.

The term 'transsexual' emerged into professional and
public usage in the 1950s as a means of designating a person who aspired to or actually lived in the anatomically contrary gender role, whether or not hormones had been administered or surgery had been performed. During the 1960s and 1970s, clinicians used the term "true transsexual." The true transsexual was thought to be a person with a characteristic path of atypical gender identity development that predicted an improved life from a treatment sequence that culminated in genital surgery. They were thought to have: 1) cross-gender identifications that were consistently expressed behaviorally in childhood, adolescence, and adulthood; 2) minimal or no sexual arousal to cross-dressing; and no heterosexual interest (relative to their anatomic sex). True transsexuals could be of either sex. "True transsexual" males were distinguished from males who arrived at the desire to change their gender via a reasonably masculine behavioral developmental pathway. Belief in the true transsexual concept for males dissipated when it was realized that: 1) such patients were rarely encountered; 2) those who requested genital reconstructive surgery more commonly had adolescent histories of fetishistic cross-dressing or autogynephilic fantasies without cross-dressing; 3) some of the original true transsexuals had falsified their histories to make their stories match the earliest theories about the disorder. The concept of "true transsexual" females never created diagnostic uncertainties, largely because patient histories were relatively consistent and gender variant behaviors, such as, female cross-dressing, remained unseen by clinicians. The term 'gender dysphoria syndrome' was then adopted to designate the presence of a gender problem in either sex until psychiatry developed an official nomenclature.

In 1994, the DSM-IV committee replaced the diagnosis of Transsexualism with Gender Identity Disorder. Depending on their age, those with a strong and persistent cross-gender identification and a persistent discomfort with his or her sex or a sense of inappropriateness in the gender role of that sex were to be diagnosed as Gender Identity Disorder of Childhood (302.6), Adolescence, or Adulthood (302.85). For persons who did not meet the criteria, Gender Identity Disorder Not Otherwise Specified (GIDNOS)(302.6) was to be used. This category included a variety of individuals--those who desire only castration or penectomy without a concomitant desire to develop breasts; those with a congenital intersex condition; those with transient stress-related cross-dressing; those with considerable ambivalence about giving up their gender roles. Patients with GID and GIDNOS were to be subclassified according to the sex of attraction: attracted to males; attracted to females; attracted to both; attracted to neither. This subclassification on the basis of orientation was intended to assist in determining over time whether individuals of one orientation or another fared better in particular approaches; it was not intended to guide treatment decisions.

Between the publication of DSM-III and DSM-IV, the term "transgendered" began to be used in various ways. Some employ it to refer to those with unusual gender identities in a value free manner-that is, without a connotation of psychopathology. Some professionals informally use the term to refer to any person with any type of gender problem. Transgendered is not a diagnosis, but professionals find it easier to informally use than GIDNOS, which is.

Contents:

Gender Identity Disorder

Diagnostic Features

Specifiers

Recording Procedures

Associated Features and Disorders

Specific Age and Gender Features

Prevalence

Course

Differential Diagnosis

Diagnostic Criteria for Gender Identity Disorder

Gender Identity Disorder not otherwise specified

Paraphilias

302.3 Transvestic Fetishism

Diagnostic Criteria for 302.3 Transvestic Fetishism

Diagnostic Features

There are two components of Gender Identity Disorder, both of which
must be present to make the diagnosis. Thee must be evidence of a strong
and persistent gross-gender identification, which is the desire to be,
or the insistence that one is of the other sex (Criteria A). This cross-gender
identification must not merely be a desire for any perceived cultural advantages
of being the other sex. there must also be evidence of persistent discomfort
about one’s assigned sex or a sense of inappropriateness in the gender
role of that sex (Criteria B). The diagnosis is not made if the individual
has a concurrent physical intersex condition (e.g., androgen insensitivity
syndrome or congenital adrenal hyperplasia) (Criteria C). To make the diagnosis,
there must be evidence of clinically significant distress or impairment
in social, occupational, or other important areas of functioning (Criteria
D).

In boys, the cross gender identification is manifested by a marked preoccupation
with traditionally feminine activities. They may have a preference for
dressing in girls’ or women’s clothes or may improvise such items from
available materials when genuine articles are unavailable. Towels, aprons,
and scarves are often used to represent long hair or skirts. There is a
strong attraction for the stereotypical games and pastimes of girls. They
particularly enjoy playing house, drawing pictures of beautiful girls and
princesses, and watching television or videos of their favorite female-type
dolls, such as Barbie, are often their favorite toys, and girls are their
preferred playmates. When playing “house”, these boys role-play female
figures. Most commonly “mother roles”, and often are quite preoccupied
with female fantasy figures. they avoid rough-and-tumble play and competitive
sports and have little interest in cars and trucks or other no-aggressive
but stereotypical boy’s toys. They may express a wish to be a girl and
assert that they will grow up to be a woman. they may insist on sitting
to urinate and pretend not to have a penis by pushing it in between their
legs. More rarely, boys with Gender Identity Disorder may state that they
find their penis or testes disgusting, that they want to remove them, or
that they have, or wish to have, a vagina.

Girls with Gender Identity Disorder display intense negative reactions
to parental expectations or attempts to have them wear dresses or other
feminine attire. Some may refuse to attend school or social events where
such clothes may be required. They prefer boy’s clothing and short hair,
are often misidentified by strangers as boys, and may ask to be called
a boy’s name. their fantasy heroes are most often powerful male figures,
such as Batman or Superman. these girls prefer boys as playmates, with
whom they share interests in contact sports, rough-and-tumble play and
traditional boyhood games. they show little interest in dolls or any form
of feminine dress up or role-play activity. A girl with this disorder may
occasionally refuse to urinate in a sitting position. She may claim that
she has or will grow a penis and may not want to grow breasts or menstruate.
She may assert that she will grow up to be a man. Such girls typically
reveal marked cross-gender identification in role-play, dreams and fantasies.

Adults with Gender Identity Disorder are preoccupied with their wish
to live as a member of the other sex. This preoccupation may be manifested
as an intense desire to adopt the social role of the other sex or to acquire
the physical appearance of the other sex through hormonal or surgical manipulation.
Adults with this disorder are uncomfortable being regarded by others as,
or functioning in society as, a member of their designated sex. To varying
degrees, they adopt the behavior, dress, and mannerisms of the other sex.
In private, these individuals may spend much time cross-dressed and working
on the appearance of being the other sex. Many attempt to pass in public
as the other sex. With cross-dressing and hormonal treatment (and for males,
electrolysis), many individuals with this disorder may pass convincingly
as the other sex. The sexual activity of these individuals with same-sex
partners is generally constrained by the preference that their partners
neither see nor touch their genitals. For some males who present later
in life, (often following marriage), sexual activity with a woman is accompanied
by the fantasy of being lesbian lovers or that his partner is a man and
he is a woman.

In adolescents, the clinical features may resemble either those of children
or those of adults, depending on the individual’s developmental level,
and the criteria should be applied accordingly. In younger adolescents,
it may be more difficult to arrive at an accurate diagnosis because of
the adolescent’s guardedness. This may be increased if the adolescent feels
ambivalent about cross-gender identification or feels that it is unacceptable
to the family. The adolescent may be referred because the parents or teachers
are concerned about social isolation or peer teasing and rejection. In
such circumstances, the diagnosis should be reserved for those adolescents
who appear quite cross-gender identified in their dress and who engage
in behaviors that suggest significant cross-gender identification (e.g.,
shaving legs in males). Clarifying the diagnosis in children and adolescents
may require monitoring over an extended period of time.

Distress or disability in individuals with Gender Identity Disorder
is manifested differently across the life cycle. in young children, distress
is manifested by the stated unhappiness about their assigned sex. Preoccupation
with cross-gender wishes often interferes with ordinary activities. In
older children, failure to develop age-appropriate same sex peer relationships
and skills often leads to isolation and distress, and some children may
refuse to attend school because of the teasing or pressure to dress in
attire stereotypical of their assigned sex. in adolescents and adults,
preoccupation with cross-gender wishes often interferes with ordinary activities.
Relationship difficulties are common and functioning at school or at work
may be impaired.

Specifiers

For sexually mature individuals, the following specifiers may be noted
based on the individual’s sexual orientation: Sexually Attracted to
Males, Sexually Attracted to Females, Sexually Attracted to Both, and
Sexually Attracted to Neither. Males with Gender Identity Disorder
include substantial proportions with all four specifiers. Virtually all
females with Gender Identity Disorder will receive the same specifier-Sexually
Attracted to Female- although there are exceptional cases involving females
who are sexually Attracted to Males.

Recording Procedures

The assigned diagnostic code depends on the individual’s current age:
if the disorder occurs in childhood, the code 302.6 is used; for an adolescent
or adult, 302.85 is used.

Associated Features and Disorders

Associated descriptive features and mental disorders.
Many individuals with Gender Identity Disorder become socially isolated.
Isolation and ostracism contribute to low self esteem and may lead to school
aversion or dropping out of school. Peer ostracism and teasing are especially
common sequelae for boys with the disorder. Boys with Gender Identity Disorder
often show marked feminine mannerisms and speech patterns.

The disturbance can be so pervasive that the mental lives of some individuals
revolve only around those activities that lessen gender distress. they
are often preoccupied with appearance, especially early in the transition
to living in the opposite sex role. Relationships with one or both parents
also may be seriously impaired. Some males with Gender Identity Disorder
resort to self-treatment with hormones and may very rarely perform their
own castration or penectomy. especially in urban centers, some males with
the disorder may engage in prostitution, which places them at a high risk
for human immunodeficiency virus (HIV) infection. Suicide attempts and
Substance-Related Disorders are commonly associated.

Children with Gender Identity Disorder may manifest coexisting Separation
Anxiety Disorder, Generalized Anxiety Disorder, and symptoms of depression.
Adolescents are particularly at risk for depression and suicidal ideation
and suicide attempts. In adults, anxiety and depressive symptoms may be
present. Some adult males have a history of Transvestic Fetishism as well
as other paraphilias. Associated Personality Disorders are more common
among males than among females being evaluated at adult gender clinics.

Associated laboratory findings.
There is no diagnostic test specific for Gender Identity Disorder. In the
presence of a normal physical examination, karyotyping for sex chromosomes
and sex hormone assays are usually not indicated. Psychological testing
may reveal cross-gender identification of behavior patterns.

Associated physical examination findings and general medical conditions.
Individuals with Gender Identity Disorder have normal genitalia (in contrast
to the ambiguous genitalia or hypogonadism found in physical intersex conditions).
Adolescents and adult males with Gender Identity Disorder may show breast
enlarement resulting from hormone ingestion, hair denuding from temporary
or permanent epilation, and other physical changes as a result of procedures
such as rhinoplasty or thyroid cartilage shaving (surgical reduction of
the Adam’s Apple). Distorted breasts or breast rashes may be een in females
who wear breast binders. Postsurical complications in genetic females include
prominent chest wall scars, and in generic males, vaginal strictures, rectovaginal
fistulas, urethral stenoses, and misdirected urinary streams. Adult females
with Gender Identity Disorder may have a higher than expected liklihood
of polycystic ovarian disease.

Specific Age and Gender Features

Females with Gender Identity Disorders generally experience less ostracism
because of cross-gender interests and may suffer less from peer rejection,
at least until adolescence. In child clinic samples, there are approximately
five boys for each girl referred with this disorder. In adult clinic samples,
men outnumber women by about two or three times. In children, the referral
bias towards males may partly reflect the greater stigma that gross-gender
behavior carries for boys than for girls.

Prevalence

There are no recent epidemiological studies to provide data on prevalence
of Gender Identity Disorder. Data from smaller countries in Europe with
access to total population statistics and referrals suggest that roughly
1 per 30,000 adult males and 1 per 100,000 adult females seek sex-reassignment
surgery.

Course

For clinically referred children, onset of cross-gender interests and
activities is usually between ages 2 and 4 years, and some parents report
that their child has always had cross-gender interests. Only a very small
number of children with gender Identity Disorder will continue to have
symptoms that meet criteria for Gender Identity Disorder in later adolescence
or adulthood. Typically, children are referred around the time of school
entry because of parental concern that what they regarded as a phase does
not appear to be passing. Most children with Gender Identity Disorder display
less overt cross-gender behaviors with time, parental intervention, or
response from peers. By late adolescence or adulthood, about three-quarters
of boys who had a childhood history of Gender Identity Disorder report
a homosexual or bisexual orientation, but without concurrent Gender Identity
Disorder. Most of the remainder report a heterosexual orientation, also
without concurrent Gender Identity Disorder. The corresponding percentages
for sexual orientation in girls are not known. some adolescents may develop
a clearer cross-gender identification and request sex-reassignment surgery
or may continue in a chronic course of gender confusion or dysphoria.

In adult males, there are two diferent cources for the development of
Gender Identity Disorder. The first is a continuation of Gender Identity
Disorder that had an onset in childhood or early adolescence. These individuals
typically present in late adolescence or adulthood. In the other course,
the more overt signs of cross-gender identification appear later and more
gradually, with a clinical presentation in early to mid-adulthood usually
following, but sometimes concurrent with, Transvestic Fetishism. The later-onset
group may be more fluctuating in the degree of cross-gender identification,
more ambivalent about sex-reassignment surgery, more likely to be sexually
attracted to women, and less likely to be satisfied after sex-reassignment
surgery. Males with Gender Identity disorder who are sexually attracted
to males tend to present in adolescence or early childhood with a lifelong
history of gender dysphoria. In contrast, those who are sexually attracted
to females, to both males and females, or to neither sex tend to present
later and typically have a history of Transvestic Fetishism. If Gender
Identity Disorder is present in adulthood, it tends to have a chronic course,
but spontaneous remission has been reported.

Differential Diagnosis

Gender Identity disorder can be distinguished from simple noncomformity
to stereo-typical sex role behavior by the extent and pervasiveness
of the cross-gender wishes, interests, and activities. This disorder is
not meant to describe a child’s nonconformity to stereotypic sex-role behavior
as, for example, in “tomboyishness” in girls or “sissyish” behavior in
boys. Rather, it represents a profound disturbance of the individual’s
sense of identity with regard to maleness or femaleness. Behavior in children
that merely does not fit the cultural stereotype of masculinity or femininity
should not be given the diagnosis unless the full syndrome is present,
including marked distress or impairment.

Tranvetic Fetishism occurs in heterosexual (or bisexual) men
for whom the cross-dressing behavior is for the purpose of sexual excitement.
Aside from cross-dressing, most individuals with Transvetic Fetishism do
not have a history of childhood cross-gender behaviors. Males with presentation
that meets full criteria for Gender Identity Disorder as well as Tranvestic
Fetishism should be given both diagnoses. If gender dysphoria is present
in an individual with Transvetic Fetishism but full criteria for Gender
Identity Disorder are not met, the specifier With Gender Dysphoria can
be used.

The category Gender Identity Disorder Not Otherwise specified
can be used for individuals who have a gender identity problem with concurrent
congenital intersex condition (e.g., androgen insensitivity syndrome
or congenital adrenal hyperplasia).

In Schizophrenia, there may rarely be delusions of belonging to the
other sex. Insistence by a person with Gender Identity Disorder that he
or she is of the other sex is not considered a delusion, because what is
invariably meant is that the person feels like a member of the other sex
rather than truley believes that he or she is a member of the other sex.
In very rare cases, however, Schizophrenia and severe Gender Identity Disorder
may coexist.

Diagnostic Criteria for gender Identity Disorder

A A strong persistent cross-gender identification (not merely
a desire for any perceived cultural advantages of being the other sex).
In children, the disturbance is manifested by four (or more) of the following:

Repeatedly stated desire to be, or insistence that he or she is, the
other sex.

In boys, preference for cross-dressing or simulating female attire;
In girls, insistence on wearing only stereotypical masculine clothing.

Strong and persistent preferences for cross-sex roles in make believe
play or persistent fantasies of being the other sex.

Intense desire to participate in the stereotypical games and pastimes
of the other sex.

Strong preference for playmates of the other sex.

In adolescents and adults, the disturbance is manifested by symptoms
such as a stated desire to be the other sex, frequent passing as the other
sex, desire to live or be treated as the other sex, or the conviction that
he or she has the typical feelings and reactions of the other sex.

B Persistent discomfort with his or her sex or sense of inappropriateness
in the gender role of that sex.

In children, the disturbance is manifested by any of the following:
In boys, assertion that his penis or testes are disgusting or will disappear
or assertion that it would be better not to have a penis, or aversion toward
rough-and-tumble play and rejection of male stereotypical toys, games,
and activities.
In girls, rejection of urinating in a sitting position, assertion that
she has or will grow a penis, or assertion that she does not want to grow
breasts or menstruate, or marked aversion toward normative feminine clothing.

In adolescents and adults, the disturbance is manifested by symptoms
such as preoccupation with getting rid of primary and secondary sex characteristics
(e.g., request for hormones, surgery, or other procedures to physically
alter sexual characteristics to simulate the other sex) or belief that
he or she was born the wrong sex.

C. The disturbance is not concurrent with physical intersex
condition.

D. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas of functioning.

Code based on current age:

302.6 Gender Identity Disorder in Children

302.85 Gender Identity Disorder in Adolescents or Adults

Specify if (for sexually mature individuals):

Sexually Attracted to Males

Sexually Attracted to Females

Sexually Attracted to Both

Sexually Attracted to Neither

302.6 Gender Identity Disorder Not Otherwise Specified

This category is included for coding disorders in gender identity that
are not classifiable as a specific Gender Identity Disorder. Examples include:

Persistent preoccupation with castration or penectomy without a desire
to acquire the sex characteristics of the other sex

Paraphilias

302.3 Transvestic Fetishism

The paraphiliac focus of Transvestic Fetishism involves cross-dressing.
Usually the male with Transvestic Fetishism keeps a collection of female
clothes that he intermittently uses to cross-dress. While cross dressed,
he usually masturbates, imagining himself to be both the male and the female
object of his sexual fantasy. This disorder has been described only in
heterosexual males.Transvestic Fetishism is to be diagnosed when cross-dressing
occurs exclusively during the course of Gender Identity Disorder.

Transvestic phenomena range from occasional solitary wearing of female
clothes to extensive involvement in a transvestic subculture. Some males
wear a single item of women's apparel (e.g., underwear or hosiery) under
their masculine attire. Other males with Transvestic Fetishism dress entirely
as females and wear makeup. The degree to which the cross-dressed individual
successfully appears to be a female varies, depending on mannerisms, body
habitus, and cross-dressing skill.

When not cross-dressed, the male with Transvestic Fetishism is usually
unremarkably masculine. Although his basic preference is heterosexual,
he tends to have few sexual partners and may have engaged in occasional
homosexual acts. An associated feature may be the presence of Sexual Masochism.
The disorder typically begins with cross-dressing in childhood or early
adolescence. In many cases, the cross-dressing is not done in public until
adulthood. The initial experience may involve partial or total cross-dressing;
partial cross-dressing often progresses to complete cross-dressing.

A favored article of clothing may become erotic in itself and may be
used habitually, first in masturbation and later in intercourse. In some
individuals, the motivation for cross-dressing may change over time, temporarily
or permanently, with sexual arousal in response to the cross-dressing diminishing
or disappearing. In such instances, the cross-dressing becomes an antidote
to anxiety or depression or contributes to a sense of peace and calm.

In other individuals, gender dysphoria may emerge, especially under
situational stress with or without symptoms of depression. For a small
number of individuals, the gender dysphoria becomes a fixed part of the
clinical picture and is accompanied by the desire to dress and live permanently
as a female and to seek hormonal or surgical reassignment. Individuals
with Transvestic Fetishism often seek treatment when gender dysphoria emerges.
The subtype with Gender Dysphoria is provided to allow the clinician to
note the presence of gender dysphoria as part of Tranvestic Fetishism.

Diagnostic Criteria for 302.3 Transvestic Fetishism

A. Over a period of at least 6 months, in a heterosexual male, recurrent,
intense sexually arousing fantasies, sexual urges, or behaviors involving
cross-dressing.

B. The fantasies, sexual urges, or behaviors cause clinically significcant
distress or impairment in social, occupational, or other important areas
of functioning.

Specify if: With Gender Dysphoria: if the person has
persistent discomfort with gender role or identity

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